Succesful implementation of surgical site bundle in a resource limited setting in cardiothoracic surgery

Background: Cardiovascular surgery (CVS) is the most common surgery performed in India. There is paucity of surgical site infection (SSI) data in a resource limited setting. Due to lack of medical insurance, cost of medical expenses are borne by the patient directly, in India. Objective: To measure the burden of CVS-SSI and assess the impact of intervention bundles and the cost saving. Methods: The study was conducted in a 42 bed CVS-ICU from 2007 to 2008 in a university teaching hospital. Baseline data was collected from Jan 2007 to Sept 2008. Surgical Site intervention bundle was implemented in Oct 2007 after rigorous training and education of all stakeholders. SSI intervention bundle included pre-operative chlorhexidine bath, use of clippers, timely administration of antimicrobial prophylaxis, skin antisepsis with 10% povidone iodine and daily assessment of the wound. Outcome was measured as: (1)  length of stay (LOS), (2) readmission to the hospital and (3) mortality. Direct cost was calculated by the difference of pre and post intervention cases. It included CVsurgery procedure billing and ancillary cost-which included: lab, imaging and pharmacy charges. Indirect cost was calculated by patient's loss of job days, attendant’s/care provider loss of job days, LOS, meals etc. Opportunity cost was assessed by admitting more surgical patients owing to reduction in LOS. Results: Surgical Site Infection during the study period was reduced by half from 6.27 (n=147) to 3.23 (n=85) per 100 procedures (Table). Readmission to hosp was reduced from 4% to 2%. Antibiotic prophylaxis duration was reduced from 7days to 3 doses to 48hrs. The excess mortality due to SSI and secondary sepsis was 26%. LOS was reduced by 12days thereby reducing cost by $ 27,699 (Rs. 13,01,875) . The estimated reduction in direct cost saving was approx $32,468 (Rs. 15,26,010) and Indirect cost savings was $ 18064 (Rs. 8,49,012). Opportunity cost during the interventional period was $ 55,359 (Rs. 26,01,900).The total cost saving by reducing 62 CV SSI by implementation of SS bundle was $ 1,33,590 (Rs. 62,78,797). Conclusions: It is possible to reduce SSI in a resource limited setting by using the surgical site intervention bundle (Table).  Adult CVS-SSI rate / 100 procedures                                

Yr	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct	Nov	Dec
2007	6.1	6.3	3.0	7.2	6.0	7.3	4.3	10.1	5.8	6.6	6.7	5.3
2008	4.6	5.5	3.4	2.5	3.6	2.6	4.2	5.0	1.1	3.0	2.0	0